In vitro measurement of ciliary beat frequency in 92 children with recurrent respiratory tract problems.

BACKGROUND: Chronic or recurrent mucoid respiratory tract symptoms may be difficult to diagnose. METHOD: Ninety-two children with chronic respiratory symptoms were divided into 4 groups: 18 children with refractory asthma, 10 with bronchiectasis without dextrocardia, 18 with dextrocardia and 46 with recurrent respiratory tract infections. Except for five neonates, cytology samples were taken under general anaesthesia. Ciliary beat frequency was measured photometrically and analysed by in-house computer software. RESULTS: Nasal polyps were found in one child with normal ciliary beat frequency. Twenty-six children had no beating cilia (male to female ratio, 15:11). The effect of increasing temperature on the ciliary beat frequency of the remaining 66 patients was evaluated (42 patients, more than 30°C, median, 8.3 Hz; 24 patients, 30-37°C, median, 11.8 Hz; p = 0.0003). CONCLUSION: The measurement of ciliary beat frequency is part of the diagnostic work up of patients with persistent or recurrent respiratory tract infections.

A summative, Objective, Structured, Clinical Examination in ENT used to assess postgraduate doctors after one year of ENT training, as part of the Diploma of Otorhinolaryngology, Head and Neck Surgery.

CONTEXT: 'High stakes' postgraduate medical examinations should conform to current educational standards. In the UK and Ireland, national assessments in surgery are devised and managed through the examination structure of the Royal Colleges of Surgeons. Their efforts are not reported in the medical education literature. In the current paper, we aim to clarify this process. OBJECTIVES: To replace the clinical section of the Diploma of Otorhinolaryngology with an Objective, Structured, Clinical Examination, and to set the level of the assessment at one year of postgraduate training in the specialty. METHODS: After 'blueprinting' against the whole curriculum, an Objective, Structured, Clinical Examination comprising 25 stations was divided into six clinical stations and 19 other stations exploring written case histories, instruments, test results, written communication skills and interpretation skills. The pass mark was set using a modified borderline method and other methods, and statistical analysis of the results was performed. RESULTS: The results of nine examinations between May 2004 and May 2008 are presented. The pass mark varied between 68 and 82 per cent. Internal consistency was good, with a Cronbach's alpha value of 0.99 for all examinations and split-half statistics varying from 0.96 to 0.99. Different standard settings gave similar pass marks. CONCLUSIONS: We have developed a summative, Objective, Structured, Clinical Examination for doctors training in otorhinolaryngology, reported herein. The objectives and standards of setting a high quality assessment were met.

Staining of nasal mucosa to examine remodelling.

BACKGROUND AND OBJECTIVE: The process of embedding tissue in paraffin degrades many important molecules involved in respiratory epithelial remodelling. We therefore examined alternative methods. METHODS: Inferior turbinate and nasal polyp biopsies were either placed in formalin or immediately snap-frozen in the operating theatre. Novel protocols for staining remodelling markers were compared with current methods. RESULTS: Our method, using a mixture of three lectins, stained a significantly greater proportion of samples, compared with using Ulex europeaus lectin alone (84 vs 62 per cent; p < 0.005). Comparison of different proliferation markers showed that Ki67 was more suitable than proliferating cell nuclear antigen for frozen sections. CONCLUSIONS: This study indicates that our robust, repeatable methods for examining whole mounts and for staining capillaries, cell proliferation and nuclei on the same section of nasal mucosa are superior to current methods. The use of fresh tissue that has not been paraffin-embedded would allow a greater suite of epitopes to be examined in the future.

BSACI guidelines for the management of rhinosinusitis and nasal polyposis.

This guidance for the management of patients with rhinosinusitis and nasal polyposis has been prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI). The recommendations are based on evidence and expert opinion and are evidence graded. These guidelines are for the benefit of both adult physicians and paediatricians treating allergic conditions. Rhinosinusitis implies inflammation of the nose and sinuses which may or may not have an infective component and includes nasal polyposis. Acute rhinosinusitis lasts up to 12 weeks and resolves completely. Chronic rhinosinusitis persists over 12 weeks and may involve acute exacerbations. Rhinosinusitis is common, affecting around 15% of the population and causes significant reduction in quality of life. The diagnosis is based largely on symptoms with confirmation by nasendoscopy. Computerized tomography scans and magnetic resonance imaging are abnormal in approximately one third of the population so are not recommended for routine diagnosis but should be reserved for those with acute complications, diagnostic uncertainty or failed medical therapy. Underlying conditions such as immune deficiency, Wegener's granulomatosis, Churg-Strauss syndrome, aspirin hypersensitivity and allergic fungal sinusitis may present as rhinosinusitis. There are few good quality trials in this area but the available evidence suggests that treatment is primarily medical, involving douching, corticosteroids, antibiotics, anti-leukotrienes, and anti-histamines. Endoscopic sinus surgery should be considered for complications, anatomical variations causing local obstruction, allergic fungal disease or patients who remain very symptomatic despite medical treatment. Further well conducted trials in clearly defined patient groups are needed to improve management.

Dental otalgia.

BACKGROUND: Secondary or referred otalgia can represent a diagnostic challenge to the otolaryngologist. Collectively, dental disorders are the most common causes of secondary otalgia presenting to the ENT clinic, and may account for up to 50 per cent of referred otalgia. Temporomandibular joint dysfunction syndrome represents the most common dental cause of referred otalgia. Decay and pulpal inflammation of posterior teeth can also frequently present as otalgia. The common embryological developmental origin of both oral and dental structures and the ear is responsible for their overlapping sensory nerve supplies, and this explains referred otalgia secondary to dental and temporomandibular joint disorders. These disorders can be easily overlooked, resulting in unnecessary and costly investigations. AIMS: This review aims to give a succinct overview of common dental causes of otalgia, and to provide ENT clinicians with guidelines for performing a rapid and simple dental and temporomandibular joint examination, which will reliably diagnose or exclude dental otalgia.

Montelukast in allergic rhinitis: a systematic review and meta-analysis.

Allergic rhinitis is common. This systematic review outlines the evidence regarding montelukast in allergic rhinitis and provides a meta-analysis of its efficacy. The evidence suggests that montelukast does reduce nasal symptom score by 3.4% (95% CI: 2.5% to 4.2%) when compared with placebo. Montelukast is not as effective as topical nasal steroids or antihistamines and should therefore be regarded as second line therapy. When used, montelukast should be used in combination with an antihistamine.

Total serum IgE and IgE antibodies specific to house dust mite found in two aged-matched cohorts of children with and without otitis media with effusion.

OBJECTIVES: To determine whether otitis media with effusion (OME) is associated with elevated serum immunoglobulin E (IgE) and IgE specific for house dust mite. DESIGN: Forty-seven children who had evidence of bilateral OME, both otoscopically and on tympanometry, on two separate occasions, 3 months apart were admitted for ventilation tubes. Forty-eight children admitted for minor eye surgery who had otoscopically normal ears and no history of middle ear problems were used as controls. Bloods samples were taken under anaesthesia. Total IgE and IgE radioallergosorbent test (RAST) to house dust mite was measured by the Pharmacia Unicap 100 system. The results from the two groups were compared. SETTING: Birmingham Children's Hospital. PARTICIPANTS: Children between the ages of 3 and 10. Children with Down's syndrome, cleft lip and palate, ciliary abnormalities, known immunodeficiencies and cardiac abnormalities were excluded. MAIN OUTCOME MEASURES: Total IgE and RAST to house dust mite. A RAST of >0.35 was taken to be positive. RESULTS: There was no statistical difference between the control and study groups for the total IgE. Six children from both study and control groups had a raised house dust mite RAST. There was no difference in the levels between either group. CONCLUSIONS: Our findings indicate that there is no direct relationship between OME and biochemical evidence of allergy, specifically to house dust mite.

Management of childhood epiphora.

AIMS: To examine the effectiveness of a management protocol for childhood epiphora using a joint ophthalmological and otolaryngological team approach. METHOD: A temporally defined retrospective study of 70 children (92 eyes) undergoing surgery for persistent epiphora, despite two previous technically successful probing procedures. All the operations involved a joint approach involving a paediatric ophthalmologist and a paediatric otolaryngologist. RESULTS: In children with congenital nasolacrimal obstruction this joint approach yielded a 73% (89%) success rate, while in children with acquired nasolacrimal obstruction the success rate was 57%. CONCLUSIONS: Endonasal nasolacrimal intubation and endonasal DCR are safe and effective procedures for the management of persistent epiphora in children. They avoid the need for overnight admission and carry a minimal complication rate.

Wegener's granulomatosis and subglottic stenosis: management of the airway.

Wegener's granulomatosis is a multisystemic disease characterized by foci of necrotizing vasculitis and granuloma formation. Subglottic stenosis may occur either as a presenting feature or a late-stage manifestation of the disease, but will occur in approximately 10-20 per cent of cases. We present a series of seven cases of Wegener's granulomatosis with subglottic stenosis and discuss our management of this condition. Where there is active disease, tracheostomy is the first-line surgical treatment of respiratory obstruction, as an adjunct to full medical therapy. More aggressive or elaborate surgical treatments should be reserved for non-active cases in which patients have not required medical treatment for one year.

Nasal polyps.

Nasal polyps are as common as adult onset asthma and unilateral polyps require histological examination. Medical therapy with corticosteroids should be tried before surgery. The anatomy should be demonstrated with computed tomography before endoscopic surgery.

Nasal ciliary studies in children with chronic respiratory tract symptoms.

Ciliary abnormalities include a range of morphological dysfunctions resulting in dysmotility. These typically manifest with upper and lower respiratory symptoms later in the infancy and early childhood. The diagnosis is based on ciliary studies i.e. measurement of ciliary beat frequency (CBF). We present a series of 67 children who had nasal biopsy and ciliary studies done between 1993-2002. There were 44 boys and 23 girls of age between 1 to 17 years. In 49 (73%) cases indication of ciliary studies was chest symptoms. There were six diagnostic categories: asthma, recurrent chest infections, bronchiectasis, rhinosinusitis, dextrocardia and prematurity. Fourteen patients (20%) had dextrocardia and of these 9 had no measurable beating cilia. In the rest 5 CBF ranged 8-12.7 Hz. If the patients with dextrocardia are excluded, 5 of the 53 (10%) did not have any ciliary activity and in remaining CBF ranged 5.3-19.7 Hz. Our results showed a significant number of children with immotile cilia had associated dextrocardia. In the absence of situs inversus index of suspicion should be very high to detect these cases early. Otolaryngologists can play a key role in diagnosis because of an easy access for nasal biopsy, which is much simple than bronchial biopsies.

Allergic rhinitis: past, present and the future.

Allergic rhinitis represents a global health issue affecting between 10% to 25% of the world population, with increasing prevalence over the last decade. Although often trivialized by patients and doctors, allergic rhinitis is a significant cause of morbidity, in addition to its substantial economic impact. While allergic rhinitis is an inflammatory disorder of the upper airways, inflammation alone is insufficient to explain the chronic nature of the disease. An exciting concept which has recently emerged in asthma concerns the role of the bronchial epithelium as a key regulator of airway inflammatory and remodelling responses in asthma. It has been shown by our group that the disruption and alteration in the function of the lower airway epithelium in asthma leads to the generation of a variety of stimuli that lead to the restructuring of the airway wall. This raises interesting questions regarding a similar role for the upper airway epithelium in allergic rhinitis. This review aims to interpret past and current research into allergic rhinitis, and to address specific areas where future research is warranted, particularly in relation to the possibility of an altered upper airway epithelial phenotype in allergic rhinitis.

Serum IgA and IgG functional antibodies and their subclasses to Streptococcus pneumoniae capsular antigen found in two aged-matched cohorts of children with and without otitis media with effusion.

The relationship between acute otitis media and otitis media with effusion (OME) is uncertain and the aetiology of OME is multifactorial. Otitis media with effusion may be an inflammatory condition; both bacteria and viral infections could play a part in this inflammation. The four bacteria Streptococcus pneumoniae, Haemophilus influenza, Staphylococcus aureus and Branhamella catarrhalis cause 60% of the infections whereas S. pneumoniae accounts for up to 35%. IgA provides the dominant surface response to polysaccharide and lipopolysaccharide antigens, of which IgA2 is the main subclass. Once the mucosa has been breached, most protection is provided by IgG. IgG2 acts mainly against bacterial capsular antigens. This study looked at two groups of 50 children with and without OME who were aged between 3 and 10 years. The aims were to determine if, firstly, the levels of the serum immunoglobulins were different in the two groups, secondly whether these children made the appropriate antibody response to the capsular antigen to S. pneumoniae (PCP), and finally if there was a delay in the maturity of the IgA response. The total IgG, IgA and all subclass levels were measured using radial immunodiffusion. Levels of functional IgA and IgG were measured using ELISAs (25 patients in each group). The results were analysed with non-parametric tests. The immunoglobulin levels were within the normal levels for both groups. There were very good correlations between the IgG total anti-PCP and the IgG2 anti-PCP (R > 0.9, p = 0.001). There was a good correlation between the levels of both IgG total and IgG2 anti-PCP against IgA total anti-PCP in both groups (R > 0.85, p > 0.01). This confirms a normal antibody response between both groups of patients. The ages of the controls and patients (50 samples) were correlated with increasing titres of circulating functional antibodies (P = 0.001). This is highly suggestive of a normal age-related response. In conclusion, the findings were contradictory to our original hypothesis that there is a subtle difference in surface protection between children with and without OME. We believe that a previous history of recurrent acute otitis media is unrelated to the development of OME after 3 years of age.

Allergen immunotherapy in ENT: historical perspective.

The origins of immunology and allergy are founded upon the early 19th century microbiological studies of Jenner and Pasteur. It was discovered that the immune system could cause harm. The subspecialty of allergy began with the coining of the term by Von Pirquet in 1906 to describe disorders resulting from hyper-reaction to normally innocuous environmental agents. Understanding the scientific basis of the immune system and allergy allowed Noon and Freeman, and later Cooke, to develop allergen immunotherapy. Initially the technique was crude, but with the subsequent key discovery of IgE, more accurate methods of diagnosis (such as the radioallergosorbent test (RAST)) and treatment ensued. The efficacy of specific immunotherapy has been demonstrated by many double-blind trials culminating in the WHO position paper. DNA recombinant technology has provided detailed molecular understanding of allergic disorders, which has resulted in several novel methods of immunotherapy that are potentially safer and more effective. Use of recombinant allergens, T-cell peptides, DNA vaccination with CpG motifs or plasmid vectors and anti-IgE strategies with monoclonal antibodies are showing promise.

Infection, allergy and the hygiene hypothesis: historical perspective.

The 'hygiene hypothesis' was popularized in the late 1980s to explain the high prevalence of atopic disorders in the developed countries. It links atopic disorders and the lack of early life infections. An association between the two is not novel and dates back to the beginnings of allergy, immunology and microbiology. Allergy and infection have always been closely related and the study of one has often provided new insights into the pathobiology of the other. Early research into bacterial infections led to the discovery of the human immune system and the concept of allergy. An important relationship exists between parasite infections and the development of atopic disorders. This review traces the long and intimate historical relationship between infection and allergy.

Structured training of ENT Specialist Registrars in the out-patient clinic and theatre.

The aims of this paper are to evaluate the training in out-patients and in theatre after the recent changes in SpR training. A postal questionnaire was sent to 191 Specialist Registrars (SpRs) in England and Wales and 57 were returned (30%). There were temporal bone facilities within the hospital for 53 SpRs but only three used them because there were no temporal bones. Surgical training was more satisfactory than out-patient training. Fewer general clinics and more specialized clinics are required, and consultant supervision is still patchy and needs attention.

Occupational rhinitis: a poorly diagnosed condition.

The civil claim of occupational rhinitis may be difficult to prove on the balance of probabilities and is the responsibility of the claimant. There are two types of occupational rhinitis, an allergic rhinitis or a rhinitis due to irritation. Occupational rhinitis can be likened to occupational asthma. Particular attention must be paid to the relationship to alleged exposure and symptoms. Irritation causes symptoms during exposure that cease afterwards unless clinically obvious damage has occurred. Tobacco smoke and nicotine may also cause symptoms. A full examination, both externally and internally of the nose, mouth and eyes should be undertaken. The presence of squamous metaplasia is important. The validity of a claimant's symptoms must be checked against the medical records. Details of all occupations, compounds and protection should be noted. Manufacturing data on the compounds should also be obtained. The Health and Safety Executive publish occupational exposure limits for many industrial chemicals. Allergen-specific IgE may be raised when an allergy is considered to cause the occupational rhinitis. Nasal challenge tests have been used in Scandinavia to diagnose allergic occupational rhinitis. The sense of smell should be tested. There are two approaches, detecting threshold or recognition, which is suprathreshold. When present, three degrees of social effect occur: impairment, disability and handicap. The degree depends on the occupation of the individual.

Th2 dominance in nasal mucosa in patients with Wegener's granulomatosis.

Wegener's granulomatosis initially affects upper respiratory tract organs including the nasal mucosa in more than 90% of patients. The inflammation is typically granulomatous with associated vasculitis. T lymphocytes are usually a prominent component of the leucocyte infiltrate. Previous studies using peripheral blood T cells have implicated IFN-gamma rich Th1-type responses. This study addressed the cytokine milieu in nasal mucosa from 10 patients with active Wegener's granulomatosis using immunohistochemistry. Increased levels of CD3+ T cells and eosinophils were present compared with normal and disease controls. There was increased expression of IL-4, down-regulation of IL-2 and no detectable IFN-gamma. There was increased expression of the chemokine receptor CCR3 by infiltrating cells, consistent with an IL-4 dominant, Th2-biased response. In contrast, renal biopsy tissue from 10 patients with active Wegener's granulomatosis showed expression of IL-2 and IL-4. The Th2-type environment within nasal mucosa, often the initial site of disease activity in Wegener's, is consistent with a local allergic response in these patients.